Background
Australia is a culturally diverse nation - 43% of Australians were born overseas or have at least one parent who was born overseas [
1]. Besides English, the most commonly spoken languages in the country are Italian, Greek, Cantonese, Arabic, Vietnamese and Mandarin. The latest census shows that there are 206,590, 71,800, 24,370 and 39,970 China-born, Hong Kong-born, Taiwan-born and Singapore-born Chinese, respectively, who live in Australia [
1]. People of Chinese-speaking background make up 3.4% (669,000) of the total Australian population. Overseas and Australian scholars have found that Asians, including Chinese, have a low rate of utilization of mental health services [
2,
3]. Underutilization is likely the result of a combination of personal, sociocultural and societal factors that influence whether or not people of culturally and linguistically diverse backgrounds seek help from mental health services. Knowledge of and beliefs surrounding mental illness and available mental health services [
4,
5], cultural conceptions of the causes of mental illness [
6,
7], public and self-stigma [
8,
9], the tendency to rely on informal networks for support [
10], and practical difficulties in accessing services have been mentioned in the literature to be associated with delays in accessing mental health services [
11].
Mental health literacy refers to "knowledge and beliefs about mental disorders which aid their recognition, management or prevention" [
12]. Inherent in this concept is the assumption that individuals who have a higher level of mental health literacy will be more willing to seek professional help for themselves and/or for people whom they know may be suffering from a mental health problem. Jorm et al. conducted pioneer research [
5,
12] into the mental health literacy of Australians. In one of their studies [
5], they found that over 67% of the 910 Australian respondents were able to correctly identify major depression described in a case vignette, and that the percentages of those who considered a family doctor/GP or counselor, antidepressants, or physical activity helpful for treating depression were 80%, 48% and 92%, respectively. In a Canadian study conducted by Wang et al. [
13] using the same depression vignette, higher percentages of respondents correctly labeled the person in the vignette as suffering from depression (75.6%), considered a family doctor/GP or counselor to be helpful (89.7% and 89.3%, respectively), and said taking antidepressants or engaging in physical activities was helpful (62% and 96.5%, respectively). However, in general the mental health literacy of the Australian and Canadian samples was comparable.
Several studies have explored the mental health literacy of Chinese-speaking people. A study of the understanding of depression among Chinese-American women reported that 58% of the respondents believed that the person in the vignette suffered from a psychological disturbance, and only 13% failed to label the person's condition as depression [
14]. In studies conducted by Parker and colleagues of Chinese-speaking Australians, the researchers found that (1) Chinese people tended to deny depression or express it somatically [
15]; (2) Chinese were less likely to view a depressive episode as a disorder or to seek help for a psychological problem [
16]; (3) most Chinese confided what they perceived to be private matters only to family members or close friends [
17] and (4) many Chinese expected Western medications to provide an instant cure to all kinds of worries, without need for explanation as to how such drugs work [
17]. In addition, respondents obtained knowledge about medications more often from friends and family than from medical professionals, and seldom asked their doctors questions about the drug they were prescribed because to do so would challenge their "authority" [
17]. In a qualitative study of Chinese-speaking Australians conducted by Blignault, Ponzio, Rong and Eisenbruch [
18], knowledge of mental illness, language barriers, stigma, confidentiality concerns, service constraints and discrimination were mentioned by the participants as major barriers affecting access to mental health services. These studies have provided us with information about the perceptions of the causes of mental illness and help-seeking behaviors of Chinese-speaking Australians. However, to the best of these authors' knowledge, there was only one study that had attempted to systematically explore the nature and level of mental health literacy among Chinese-speaking people.
This study was conducted by Klimidis, Hsiao and Minas which reported that 51% of Chinese-speaking Australians were able to recognize major depression described in a vignette, that multiple labels were used by the respondents, and that 49% and 73.6% of them said that the condition was related to emotional/mental problems and stress, respectively [
19]. The authors compared their findings with those of an early study of Jorm and colleagues [
4] and concluded that Chinese-speaking Australians did not appear to have a low level of mental health literacy. Their conclusion, however, warrants further validation because the two studies did not use the same vignette and response format to solicit the opinions of the two groups of respondents. In addition, the studies of Ying [
14] and Klimidis [
19] did not use a cultural perspective to explore the variation in the preference for the type of professional help, medication and treatment method or the conception of mental illness among Chinese-speaking people. Such an understanding would enable the design of culturally relevant public education programs to enhance the mental health literacy of people of Chinese-speaking background in Australia and other countries. In this study, we used the same depression vignette and response format proposed by Jorm et al. [
20] and compared our findings with those of Jorm et al. [
20] of the mental health literacy of Australian and Japanese people. We chose these two samples for comparison based on the notion that a comparison with the Australian sample might elucidate possible cultural differences in the preference for professional help, medications and treatments between Australians and Chinese-speaking Australians. On the other hand, a comparison with the Japanese sample (who are presumed to be culturally more similar to the Chinese-speaking Australians) might illuminate socioeconomic and policy differences in the preference for professional help, medications and treatments between people in these two countries. Lastly, to explore the cultural dimension of the mental health literacy of Chinese-speaking Australians, we added a number of culturally relevant options under the professional help, medication and other treatment categories in the questionnaire.
The adoption of a certain explanatory model of the causes of mental illness affects not only a person's understanding of mental illness but also his or her choice of medication and treatment [
20,
21]. It is therefore important to explore the cultural conception of mental illness as it is highly related to the mental health literacy of cultural groups. A study conducted by Tang et al. [
22] in China found that patients who believed that they had a physical rather than a mental illness tended to seek help from qigong masters or folk healers. Studies conducted by Phillips et al. in China [
6] and Wong et al. in Hong Kong [
7] revealed that respondents highly endorsed psychosocial explanatory models such as stress, interpersonal conflict and personality deficits in explaining the causes of mental illness. There are, however, very few studies of the cultural conception of mental illness of Chinese-speaking Australians. Among them, Hsiao et al. [
21] conducted qualitative research and found that this population combined traditional with Western medical knowledge to develop their own labels for various kinds of mental disorders, which included "mental illness," "physical illness," "normal problems of living" and "psychological problems." Parker and colleagues found that Chinese people tended to deny depression or express it somatically and did not view a depressive episode as a disorder [
15‐
17].
Results
Table
1 shows the demographic characteristics of the sample. There were more females than males (69.5% vs. 30.5%, respectively). The majority of the respondents were married, between 40 and 65 years of age, spoke mainly Cantonese or Putonghua/Mandarin, and were relatively well educated, having received senior secondary to tertiary education. Most of them had been born in Hong Kong or China, and migrated to Australia, on average, about 10 years previously. Fifty-six percent had an individual income of less than AUD 20000, and 18% had an income between AUD 20001 and AUD 40000; it was estimated that the weekly income of individual respondents was around AUD 450. Among them, 41% rated their English proficiency as average, and over 46% rated it as poor to very poor. About 40% of the respondents had full- or part-time jobs, and 25% were unemployed. The demographic characteristics of our sample were comparable to those of the population of Chinese-speaking Australians and immigrants described in the Australian Census [
1] in terms of place of origin, major dialects spoken, length of time in Australia, average annual income and education level. However, in our sample, the male to female ratio was higher and there were more unemployed people [
1].
Table 1
Demographic characteristics of the respondents (N = 200)
Gender | Male | 61 | 30.5 |
| female | 139 | 69.5 |
Age | | Mean age = 49.2 Range = 19 to 78 years old | |
Education | Primary school | 6 | 3 |
| Secondary school | 23 | 11.5 |
| Senior secondary school | 57 | 28.5 |
| Diploma | 48 | 24 |
| Bachelor's degree | 38 | 19 |
| Master's degree or higher | 12 | 6 |
| Unknown | 16 | 8 |
Living in Australia (months) | | Mean stay = 125 months Range = 1 to 456 months | |
Place of origin | China | 86 | 43 |
| Hong Kong | 64 | 32 |
| Vietnam | 13 | 6.5 |
| Singapore/Malaysia | 18 | 9 |
| Taiwan | 16 | 8 |
| Other | 3 | 1.5 |
Marital status | Single | 24 | 12 |
| Married | 132 | 66 |
| Widow | 13 | 3.5 |
| Divorced | 24 | 11 |
| Cohabitating | 7 | 7.5 |
Personal income per year | 0-20000 | 112 | 56 |
| 20001-40000 | 36 | 18 |
| 40001-60000 | 17 | 8.5 |
| 60001-80000 | 9 | 4.5 |
| over 80001 | 2 | 1 |
| Unknown | 24 | 12 |
Language | Cantonese | 136 | 68 |
| Putonghua/Mandarin | 52 | 26 |
| Hakka | 4 | 2 |
| Chiu Chou | 3 | 1.5 |
| Other | 5 | 2.5 |
English ability | Very poor | 30 | 15 |
| Poor | 63 | 31.5 |
| Average | 82 | 41 |
| Good | 18 | 9 |
| Very good | 7 | 3.5 |
Employment | Full time | 40 | 20 |
| Part time | 41 | 20.5 |
| Seeking employment | 37 | 18.5 |
| Unemployed | 50 | 25 |
| Retired | 9 | 4.5 |
| Housewife | 11 | 5.5 |
| Unknown | 12 | 6 |
Table
2 shows that although many respondents believed that the person in the vignette needed help, fewer of them compared to those in the other samples [
20] identified the condition of the individual as major depression. They were more likely to consider the person to be suffering from stress or anxiety. The respondents in this study also rated professional help as more helpful and less harmful than did their Australian and Japanese counterparts in the study of Jorm et al. [
20], and preferred counseling professionals to other professionals or lay helpers, except close family members (see Table
3). The respondents in our sample and the Japanese one both believed close family members to be helpful. Interestingly, although 30% of the respondents in our sample rated traditional Chinese medicine doctors as helpful, only 2.7% rated traditional healers as helpful, and 55% suggested the latter could be harmful (Table
3).
Table 2
Percentage of respondents giving labels to the depression vignette and seeing that the person needed help
Label |
%
|
%
|
%
|
Depression | 65.3 | 22.6 | 14 (n = 28) |
Stress/anxiety | 16.6 | 25 | 26.5 (n = 53) |
Emotional disturbance | 4.5 | 29.4 | 7.5 (n = 15) |
Insomnia/lack of concentration | NA | NA | 8 (n = 16) |
No answer | NA | NA | 44 (n = 88) |
Needing help | | | |
Yes | | | 90.6 (n = 181) |
No | | | 9.4 (n = 19) |
Table 3
Percentage of respondents rating each type of professional as "helpful" or "harmful" for the person in the depression vignette (by sample)
1. Doctor | 87.3 | 30.4 | 74 | 0.5 | 9.4 | 2.1 |
2. Pharmacist | 35.4 | 6.8 | 27.6 | 8.7 | 23.6 | 8.6 |
3. Counselor | 82.2 | 85.8 | 90.2 | 3.1 | 1.0 | 0.5 |
4. Social worker | 62.8 | 73.4 | 86.9 | 4.5 | 1.4 | 1.0 |
5. Hot-line telephone counselor | 63.5 | 42.4 | 77.4 | 5.9 | 8.6 | 1.1 |
6. Psychiatrist | 65.0 | 69.4 | 73.5 | 7.1 | 5.4 | 3.7 |
7. Clinical psychologist | 66.9 | 56.6 | 83.6 | 5.1 | 6.0 | 0 |
8. Close family members | 67.9 | 85 | 82.2 | 4.9 | 1.6 | 2.1 |
9. Close friends | 78.2 | 84.8 | 76.4 | 2.1 | 1.8 | 2.6 |
10. Naturopath | 34.9 | 11.2 | 39.2 | 11.1 | 18.8 | 4.2 |
11. Religious practitioner | 45.3 | 13.6 | 58.5 | 8.1 | 24.2 | 2.1 |
12. Deal with it alone | 13.1 | 24.4 | 28.2 | 64 | 41.4 | 61.7 |
13. Traditional Chinese medicine doctor | NA | NA | 31.8 | NA | NA | 8.0 |
14. Traditional healer | NA | NA | 2.7 | NA | NA | 54.9 |
Table
4 shows that Chinese-speaking Australians were more equivocal about the helpfulness or harmfulness of certain medications on the list, especially sleeping pills, antipsychotics and tranquilizers, than the respondents in the study of Jorm et al. [
20]. Higher percentages of respondents in the Chinese-speaking Australian and Japanese samples indicated that they were unsure about the usefulness or harmfulness of certain medications compared to the Australian sample. In addition, Australians generally rated medications as more harmful than did either the Chinese-speaking Australians or Japanese. Forty-one percent of Chinese-speaking Australians indicated that antidepressants would be helpful to the person in the vignette, compared to 34.8% and 46.7% of Japanese and Australians, respectively. Lastly, 17.4% of the respondents in the present study rated Chinese herbal medications as helpful. However, a similar percentage thought that they could be harmful (Table
4).
Table 4
Percentage of respondents rating each type of medication as "helpful" or "harmful" for the person in the depression vignette (by sample)
1. Vitamins, minerals | 50.2 | 20.2 | 26.8 | 4.4 | 14.6 | 5.7 |
2. St. John's wort | NA | NA | 2.6 | NA | NA | 17.5 |
3. Pain relievers | 14.8 | 4.4 | 6.8 | 37.7 | 43.4 | 55.7 |
4. Antidepressants | 46.7 | 34.8 | 40.9 | 27.5 | 18.2 | 14 |
5. Antibiotics | 10.4 | 6.2 | 37.5 | 38.3 | 29.8 | 4.4 |
6. Sleeping pills | 23.9 | 31.6 | 31.1 | 49.6 | 27.0 | 31.1 |
7. Antipsychotics | 11.2 | 22.6 | 27.5 | 48.3 | 19 | 25.9 |
8. Tranquilizers | 13.8 | 38.4 | 26.4 | 60.4 | 15.8 | 29.0 |
9. Chinese herbal medicines | NA | NA | 17.4 | NA | NA | 18.5 |
Both our subjects and the Australians in the study of Jorm et al. [
20] highly endorsed the notion of lifestyle changes (i.e., engage in physical activities, get out more, learn to relax) as helpful for the person in the vignette (Table
5). However, the percentages in these areas were lower among the Japanese sample. Psychotherapy was also rated very highly by our respondents, more so than that in either the Australian or the Japanese sample. In our study, about 33% and 27% of the respondents considered consuming Chinese nutritional foods/supplements and practicing qiqong, respectively, to be helpful, whereas very few perceived changing fungshui or traditional Chinese worship to be helpful. About half of the respondents indicated that traditional Chinese worship was harmful (Table
5).
Table 5
Percentage of respondents rating each type of intervention as "helpful" or "harmful" for the person in the depression vignette (by sample)
1. Physical activity | 92.0 | 69.4 | 97.5 | 0.8 | 3.6 | 0.5 |
2. Read about problem | 79.3 | 60 | 64.6 | 4.1 | 7.6 | 4.1 |
3. Get out more | 87.0 | 67.0 | 60.2 | 0.4 | 3.0 | 8.9 |
4. Learn to relax | 83.6 | 38.0 | 83.1 | 1.5 | 7.6 | 0 |
5. Cut out alcohol | 56.0 | 10.0 | 82.6 | 4.7 | 17.2 | 4.6 |
6. Psychotherapy | 44.1 | 49.0 | 89.8 | 10.0 | 7.4 | 0 |
7. Cognitive behavioral treatment | NA | NA | 69.6 | NA | NA | 0.5 |
8. Hypnosis | 22.4 | 28.0 | 27.8 | 17.0 | 14.2 | 7.2 |
9. Psychiatric ward | 16.4 | 13.6 | 15.0 | 53.3 | 43.0 | 34.2 |
10. Electroconvulsive treatment (ECT) | 5.9 | 2.2 | 9.4 | 69.4 | 50.2 | 16.1 |
11. Occasional drink | 44.4 | 31.4 | 10.3 | 15.4 | 17.4 | 44.1 |
12. Taking Chinese nutritional foods/supplements | NA | NA | 32.6 | NA | NA | 11.9 |
13. Qigong | NA | NA | 26.9 | NA | NA | 9.3 |
14. Changing fungshui | NA | NA | 5.8 | NA | NA | 27.7 |
15. Traditional Chinese worship | NA | NA | 4.2 | NA | NA | 51.6 |
Table
6 documents the conceptions of the respondents in this study of the causes of mental illness. Items related to psychosocial perspective were rated highly, including life stress, negative life experience and interpersonal conflict. Personality factors including introverted personality and "think too much" also received high ratings. Traditional beliefs such as "punishment for misdeeds conducted by ancestors" and "demon possession" had the lowest ratings. The findings indicate that the Chinese-speaking Australians in this sample endorsed psychosocial rather than traditional perspectives of the causes of mental illness.
Table 6
Cause of mental illness as perceived by respondents
1. Life stress (e.g. work, study or finance) | 4.10 |
2. Introverted personality | 3.90 |
3. Negative life experience | 3.89 |
4. Think too much | 3.83 |
5. Chemical imbalance in the brain | 3.63 |
6. Genetic pre-disposition | 3.63 |
7. Interpersonal conflicts | 3.47 |
8. Too much qiqong practice | 2.52 |
9. Yin Yang Imbalance | 2.51 |
10. Fate | 1.93 |
11. Demon possession | 1.68 |
12. Punishment for the misdeed conducted by ancestors | 1.61 |
13. Bad Fung Shui
| 1.58 |
Fu Keung Daniel Wong, School of Nursing and Social Work, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Level 5, 234 Queensberry Street, Carlton, Melbourne, Victoria, Australia, 3053. Telephone: (613) 8344-9408; fax: (613) 9347-4375; e-mail: fwong@unimelb.edu.au (Corresponding author)
Yuk Kit Angus Lam, Centre for Cognitive Behavioural Therapy and Training for Chinese People, Department of Social Work and Social Administration, University of Hong Kong, Hong Kong, China. E-mail: anguslyk@hku.hk
Ada Poon, Community Settlement Services, Chinese Community Social Services Centre Inc., Melbourne, Victoria, Australia. E-mail: ada@ccssci.com.au
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
FKDW initiated the research, translated and drafted the questionnaire, analyzed the data and wrote the first draft of the manuscript. YKAL contributed ideas to the design of the questionnaire and commented on the draft of the manuscript. AP and her agency helped out in the data collection. All authors have read the final manuscript and approved its contents.